Effects of omega-3 polyunsaturated fatty acids on psychophysiological symptoms of post-traumatic stress disorder in accident survivors: A randomized, double-blind, placebo-controlled trial

Omega-3 world map: 2024 update

In 2016, the first worldwide n3 PUFA status map was published using the Omega-3 Index (O3I) as standard biomarker. The O3I is defined as the percentage of EPA + DHA in red blood cell (RBC) membrane FAs. The purpose of the present study was to update the 2016 map with new data. In order to be included, studies had to report O3I and/or blood EPA + DHA levels in metrics convertible into an estimated O3I, in samples drawn after 1999. To convert the non-RBC-based EPA + DHA metrics into RBC we used newly developed equations. Baseline data from clinical trials and observational studies were acceptable. A literature search identified 328 studies meeting inclusion criteria encompassing 342,864 subjects from 48 countries/regions. Weighted mean country O3I levels were categorized into very low ≤4%, low >4-6%, moderate >6-8%, and desirable >8%. We found that the O3I in most countries was low to very low. Notable differences between the current and 2016 map were 1) USA, Canada, Italy, Turkey, UK, Ireland and Greece (moving from the very low to low category); 2) France, Spain and New Zealand (low to moderate); and 3) Finland and Iceland (moderate to desirable). Countries such as Iran, Egypt, and India exhibited particularly poor O3I levels.

Efficacy of Polyunsaturated Fatty Acids as a Treatment for Post-traumatic Stress Disorder: A Systematic Review

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a prevalent health condition among members of the military. Although the efficacy of pharmacological and psychiatric interventions for PTSD has been well studied, there are limited data on the effects of omega-3 (n-3) polyunsaturated fatty acid (PUFA) interventions on PTSD. The use of PUFAs shows promise because of their neuroprotective effects. Thus, this systematic review will synthesize the current state of the evidence regarding the effectiveness of PUFA treatment for PTSD.

MATERIALS AND METHODS

Using the PubMed, PsychINFO, Embase, and CINAHL databases, a search of the literature was conducted using the search terms "posttraumatic-stress-disorder, combat disorders, trauma-related-stress-disorder, omega-3, fatty acid, and polyunsaturated fatty acids" to identify articles published from January 1, 2008, to January 1, 2024, that focused on PUFA interventions for PTSD. A total of 281 articles were identified. Following exclusions and quality assessments using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria proposed by Cochrane, 6 randomized controlled trials (RCTs) and preclinical studies were chosen for inclusion, and data were then extracted into a data matrix for final synthesis and analysis.

RESULTS

The RCTs (n = 3) showed no significant effect of PUFAs in the prevention of PTSD symptom onset. Among preclinical studies (n = 3), PUFAs resulted in a significant decrease in anxiety-like behavior and fear memory and an increase in spatial learning and memory. The quality of evidence among the 6 RCTs and preclinical studies using the Cochrane GRADE criteria ranged from low to high.

CONCLUSIONS

The results from this systematic review suggest that more evidence is needed before making any recommendations for the clinical use of dietary PUFAs in the management of PTSD symptoms.

Early pharmacological interventions for prevention of post-traumatic stress disorder (PTSD) in individuals experiencing acute traumatic stress symptoms

BACKGROUND

Acute traumatic stress symptoms may develop in people who have been exposed to a traumatic event. Although they are usually self-limiting in time, some people develop post-traumatic stress disorder (PTSD), a severe and debilitating condition. Pharmacological interventions have been proposed for acute symptoms to act as an indicated prevention measure for PTSD development. As many individuals will spontaneously remit, these interventions should balance efficacy and tolerability.

OBJECTIVES

To assess the efficacy and acceptability of early pharmacological interventions for prevention of PTSD in adults experiencing acute traumatic stress symptoms.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase and two other databases. We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 23 January 2023.

SELECTION CRITERIA

We included randomised controlled trials on adults exposed to any kind of traumatic event and presenting acute traumatic stress symptoms, without restriction on their severity. We considered comparisons of any medication with placebo, or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Using a random-effects model, we analysed dichotomous data as risk ratios (RR) and calculated the number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD). Our primary outcomes were PTSD severity and dropouts due to adverse events. Secondary outcomes included PTSD rate, functional disability and quality of life.

MAIN RESULTS

We included eight studies that considered four interventions (escitalopram, hydrocortisone, intranasal oxytocin, temazepam) and involved a total of 779 participants. The largest trial contributed 353 participants and the next largest, 120 and 118 participants respectively. The trials enrolled participants admitted to trauma centres or emergency departments. The risk of bias in the included studies was generally low except for attrition rate, which we rated as high-risk. We could meta-analyse data for two comparisons: escitalopram versus placebo (but limited to secondary outcomes) and hydrocortisone versus placebo. One study compared escitalopram to placebo at our primary time point of three months after the traumatic event. There was inconclusive evidence of any difference in terms of PTSD severity (mean difference (MD) on the Clinician-Administered PTSD Scale (CAPS, score range 0 to 136) -11.35, 95% confidence interval (CI) -24.56 to 1.86; 1 study, 23 participants; very low-certainty evidence), dropouts due to adverse events (no participant left the study early due to adverse events; 1 study, 31 participants; very low-certainty evidence) and PTSD rates (RR 0.59, 95% CI 0.03 to 13.08; NNTB 37, 95% CI NNTB 15 to NNTH 1; 1 study, 23 participants; very low-certainty evidence). The study did not assess functional disability or quality of life. Three studies compared hydrocortisone to placebo at our primary time point of three months after the traumatic event. We found inconclusive evidence on whether hydrocortisone was more effective in reducing the severity of PTSD symptoms compared to placebo (MD on CAPS -7.53, 95% CI -25.20 to 10.13; I2 = 85%; 3 studies, 136 participants; very low-certainty evidence) and whether it reduced the risk of developing PTSD (RR 0.47, 95% CI 0.09 to 2.38; NNTB 14, 95% CI NNTB 8 to NNTH 5; I2 = 36%; 3 studies, 136 participants; very low-certainty evidence). Evidence on the risk of dropping out due to adverse events is inconclusive (RR 3.19, 95% CI 0.13 to 75.43; 2 studies, 182 participants; low-certainty evidence) and it is unclear whether hydrocortisone might improve quality of life (MD on the SF-36 (score range 0 to 136, higher is better) 19.70, 95% CI -1.10 to 40.50; 1 study, 43 participants; very low-certainty evidence). No study assessed functional disability.

AUTHORS' CONCLUSIONS

This review provides uncertain evidence regarding the use of escitalopram, hydrocortisone, intranasal oxytocin and temazepam for people with acute stress symptoms. It is therefore unclear whether these pharmacological interventions exert a positive or negative effect in this population. It is important to note that acute traumatic stress symptoms are often limited in time, and that the lack of data prevents the careful assessment of expected benefits against side effects that is therefore required. To yield stronger conclusions regarding both positive and negative outcomes, larger sample sizes are required. A common operational framework of criteria for inclusion and baseline assessment might help in better understanding who, if anyone, benefits from an intervention. As symptom severity alone does not provide the full picture of the impact of exposure to trauma, assessment of quality of life and functional impairment would provide a more comprehensive picture of the effects of the interventions. The assessment and reporting of side effects may facilitate a more comprehensive understanding of tolerability.

Post-Traumatic Stress Disorder/Developmental Trauma Disorder/Complex Post-Traumatic Stress Disorder and Complementary and Integrative Medicine/Functional Medicine

Response to PTSD treatments differ based on the age the abuse occurred, the type of abuse, and the chronicity of the abuse. Even when modifications to treatment are made based on the developmental age when the abuse occurred, therapies may be insufficient. In addition, when diagnostic criteria are modified to identify more children, some children continue to escape detection. Developmental Trauma Disorder, (akin to the RDoC), may be more suitable to identify epigenetic and inflammatory effects of early abuse that may be responsible for the nonresponsive to treatment. Complementary and Integrative Medicine interventions (meditation, EFT, EMDR, PUFAs, etc.) may reverse these effects.

Omega-3 fatty acid intake during pregnancy and risk of infant maltreatment: a nationwide birth cohort - the Japan Environment and Children's Study

BACKGROUND

Intake of omega-3 polyunsaturated fatty acids (PUFAs) has favorable effects, including reducing violent and aggressive behaviors, but its association with infant maltreatment is unknown. We therefore tested the hypothesis that maternal intake of omega-3 PUFAs is associated with a lower risk of infant maltreatment.

METHODS

Participants were 92 191 mothers involved in the ongoing Japan Environment and Children's Study. Omega-3 PUFA intake during pregnancy was measured using a food frequency questionnaire. Infant maltreatment was assessed using a self-reported questionnaire administered at 1 and 6 months postpartum.

RESULTS

Analysis using the lowest quintile of intake as a reference revealed that the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for cases of 'hitting' decreased as quintiles increased, with values for the second to fifth quintiles of 0.93 (95% CI 0.77-1.13), 0.79 (95% CI 0.64-0.97), 0.78 (95% CI 0.64-0.96), and 0.72 (95% CI 0.59-0.89), respectively. Adjusted ORs (95% CIs) for 'shaking very hard' at 6 months were 0.87 (0.73-1.04), 0.81 (0.67-0.97), 0.73 (0.61-0.89), and 0.78 (0.65-0.94), respectively. Adjusted ORs for 'leaving alone at home' for the second to fifth quintiles were 0.92 (0.87-0.98), 0.91 (0.86-0.97), 0.94 (0.88-0.99), and 0.85 (0.80-0.90), respectively.

CONCLUSIONS

Higher maternal intake of omega-3 PUFAs during pregnancy was associated with fewer cases of hitting and violent shaking and leaving the child alone at home, implying a lower risk of infant maltreatment. Our results indicate the potential applicability of omega-3 PUFAs in reducing infant maltreatment.

Early pharmacological interventions for universal prevention of post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder (PTSD) is a severe and debilitating condition. Several pharmacological interventions have been proposed with the aim to prevent or mitigate it. These interventions should balance efficacy and tolerability, given that not all individuals exposed to a traumatic event will develop PTSD. There are different possible approaches to preventing PTSD; universal prevention is aimed at individuals at risk of developing PTSD on the basis of having been exposed to a traumatic event, irrespective of whether they are showing signs of psychological difficulties.

OBJECTIVES

To assess the efficacy and acceptability of pharmacological interventions for universal prevention of PTSD in adults exposed to a traumatic event.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase, two other databases and two trials registers (November 2020). We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 13 November 2020.

SELECTION CRITERIA

We included randomised clinical trials on adults exposed to any kind of traumatic event. We considered comparisons of any medication with placebo or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. In a random-effects model, we analysed dichotomous data as risk ratios (RR) and number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD).

MAIN RESULTS

We included 13 studies which considered eight interventions (hydrocortisone, propranolol, dexamethasone, omega-3 fatty acids, gabapentin, paroxetine, PulmoCare enteral formula, Oxepa enteral formula and 5-hydroxytryptophan) and involved 2023 participants, with a single trial contributing 1244 participants. Eight studies enrolled participants from emergency departments or trauma centres or similar settings. Participants were exposed to a range of both intentional and unintentional traumatic events. Five studies considered participants in the context of intensive care units with traumatic events consisting of severe physical illness. Our concerns about risk of bias in the included studies were mostly due to high attrition and possible selective reporting. We could meta-analyse data for two comparisons: hydrocortisone versus placebo, but limited to secondary outcomes; and propranolol versus placebo. No study compared hydrocortisone to placebo at the primary endpoint of three months after the traumatic event. The evidence on whether propranolol was more effective in reducing the severity of PTSD symptoms compared to placebo at three months after the traumatic event is inconclusive, because of serious risk of bias amongst the included studies, serious inconsistency amongst the studies' results, and very serious imprecision of the estimate of effect (SMD -0.51, 95% confidence interval (CI) -1.61 to 0.59; I² = 83%; 3 studies, 86 participants; very low-certainty evidence). No study provided data on dropout rates due to side effects at three months post-traumatic event. The evidence on whether propranolol was more effective than placebo in reducing the probability of experiencing PTSD at three months after the traumatic event is inconclusive, because of serious risk of bias amongst the included studies, and very serious imprecision of the estimate of effect (RR 0.77, 95% CI 0.31 to 1.92; 3 studies, 88 participants; very low-certainty evidence). No study assessed functional disability or quality of life.  Only one study compared gabapentin to placebo at the primary endpoint of three months after the traumatic event, with inconclusive evidence in terms of both PTSD severity and probability of experiencing PTSD, because of imprecision of the effect estimate, serious risk of bias and serious imprecision (very low-certainty evidence). We found no data on dropout rates due to side effects, functional disability or quality of life. For the remaining comparisons, the available data are inconclusive or missing in terms of PTSD severity reduction and dropout rates due to adverse events. No study assessed functional disability.

AUTHORS' CONCLUSIONS

This review provides uncertain evidence only regarding the use of hydrocortisone, propranolol, dexamethasone, omega-3 fatty acids, gabapentin, paroxetine, PulmoCare formula, Oxepa formula, or 5-hydroxytryptophan as universal PTSD prevention strategies. Future research might benefit from larger samples, better reporting of side effects and inclusion of quality of life and functioning measures.

Effect of smartphone app on post-traumatic stress disorder in COVID-19 convalescent patients: A protocol for systematic review and meta-analysis

BACKGROUND

The outbreak of Coronavirus Disease 2019 (COVID-19) seriously affects humans' health worldwide physically and mentally. Studies revealed that the prevalence of post-traumatic stress disorder (PTSD) increased under this condition. PTSD can change the structure of patients' central nervous system, and increase the risk of anxiety or depression, thus greatly affecting the quality of patients' life and their families. PTSD is preventable, and the effects of early prevention are better. Non-drug intervention can prevent or reduce the psychological sequelae after hospitalization, help patients understand the experience during hospitalization, and be beneficial to their psychological rehabilitation. Whether smartphone app based intervention can be an alternative therapy for PTSD in terms of COVID-19 convalescent patients is still controversial. Therefore, we conducted a meta-analysis and systematic review to evaluate the effects of smartphone app based intervention on PTSD in COVID-19 convalescent patients, so as to provide some guidance for clinical application.

METHODS

The literatures that are related to the smartphone app based intervention and PTSD in COVID-19 convalescent patients from inception to February 2021 will be searched. The following databases are our focused areas: ClinicalTrials.gov, Cochrane Central Register of Controlled Trials repositories, PubMed, EmBase, and Web of Science databases. According to the inclusion and exclusion criteria, 2 investigators would independently screen the literature extract data and evaluate the risk of bias in the included studies. Meta-analysis was performed with RevMan5.3 software.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSION

The conclusion of our study could provide evidence for the judgment of whether smartphone app based intervention is an effective intervention on PTSD in COVID-19 convalescent patients.

PROSPERO REGISTRATION NUMBER

CRD42021240340.

The association between body mass index and recovery from post-traumatic stress disorder after the nuclear accident in Fukushima

Post-traumatic stress disorder (PTSD) and obesity share common risk factors; however, the effect of obesity on recovery from PTSD has not been assessed. We examined the association between body mass index (BMI) and recovery from PTSD after the Great East Japan Earthquake. We analyzed 4356 men and women with probable PTSD aged ≥ 16 years who were living in evacuation zones owing to the radiation accident in Fukushima, Japan. Recovery from probable PTSD was defined as Post-traumatic Stress Disorder Checklist-specific scores < 44. Using Poisson regression with robust error variance adjusted for confounders, we compared the prevalence ratios (PRs) and 95% confidence intervals (CIs) for this outcome in 2013 and 2014. Compared with point estimates for normal weight (BMI: 18.5-24.9 kg/m2), especially in 2013, those for underweight (BMI: < 18.5 kg/m2) and obesity (BMI: ≥ 30.0 kg/m2) tended to slightly increase and decrease, respectively, for recovery from probable PTSD. The multivariate-adjusted PRs (95% CIs) for underweight and obesity were 1.08 (0.88-1.33) and 0.85 (0.68-1.06), respectively, in 2013 and 1.02 (0.82-1.26) and 0.87 (0.69-1.09), respectively, in 2014. The results of the present study showed that obesity may be a useful predictor for probable PTSD recovery. Obese victims with PTSD would require more intensive support and careful follow-up for recovery.

The role of glucocorticoid receptors in the induction and prevention of hippocampal abnormalities in an animal model of posttraumatic stress disorder

RATIONALE

Since the precise mechanisms of posttraumatic stress disorder (PTSD) remain unknown, effective treatment interventions have not yet been established. Numerous clinical studies have led to the hypothesis that elevated glucocorticoid levels in response to extreme stress might trigger a pathophysiological cascade which consequently leads to functional and morphological changes in the hippocampus.

OBJECTIVES

To elucidate the pathophysiology of PTSD, we examined the alteration of hippocampal gene expression through the glucocorticoid receptor (GR) in the single prolonged stress (SPS) paradigm, a rat model of PTSD.

METHODS

We measured nuclear GRs by western blot, and the binding of GR to the promoter of Bcl-2 and Bax genes by chromatin immunoprecipitation-qPCR as well as the expression of these 2 genes by RT-PCR in the hippocampus of SPS rats. In addition, we examined the preventive effects of a GR antagonist on SPS-induced molecular, morphological, and behavioral alterations (hippocampal gene expression of Bcl-2 and Bax, hippocampal apoptosis using TUNEL staining, impaired fear memory extinction (FME) using the contextual fear conditioning paradigm).

RESULTS

Exposure to SPS increased nuclear GR expression and GR binding to Bcl-2 gene, and decreased Bcl-2 mRNA expression. Administration of GR antagonist immediately after SPS prevented activation of the glucocorticoid cascade, hippocampal apoptosis, and impairment FME in SPS rats.

CONCLUSION

The activation of GRs in response to severe stress may trigger the pathophysiological cascade leading to impaired FME and hippocampal apoptosis. In contrast, administration of GR antagonist could be useful for preventing the development of PTSD.

Fatty Fish Intervention and Psychophysiological Responses to Mental Workload in Forensic Inpatients

Abstract. The overall aim of this randomized controlled trial was to investigate the effect of a long-term fatty fish intervention during winter time on psychophysiological responses, that is, heart rate variability (HRV), to mental workload. Forty-seven forensic inpatients were randomly assigned into a fish group (FG) or a control group (CG). HRV responses to an experimental test procedure consisting of a resting baseline, mental workload, and a resting recovery were measured pre- and post-intervention. The results revealed that the FG showed attenuated physiological responses to mental workload from pretest to posttest by a significant increase in HRV. Additionally, the FG showed a higher HRV during recovery compared to the baseline and test conditions at both pretest and posttest. The CG showed no changes in psychophysiological responses from pretest to posttest to mental workload. Importantly, the CG showed impaired recovery at posttest, indicating a sustained physiological arousal after the stressor (mental workload) ended. Thus, the results indicate that increased fatty fish intake has the potential to increase resilience to mild cognitive stress in human beings with psychiatric illnesses.

Polyunsaturated Fatty Acids: What is Their Role in Treatment of Psychiatric Disorders?

In the central nervous system omega-3 fatty acids modulate cell signaling and affect dopaminergic and serotonergic pathways. On this basis, a new application for omega-3 fatty acids has been proposed, concerning the treatment of several psychiatric disorders. The present article is an update of a previous systematic review and is aimed to provide a complete report of data published in the period between 1980 and 2019 on efficacy and tolerability of omega-3 fatty acids in psychiatric disorders. In July 2019, an electronic search on PUBMED, Medline and PsychINFO of all RCTs, systematic reviews and meta-analyses on omega-3 fatty acids and psychiatric disorders without any filter or MESH restriction was performed. After eligibility processes, the final number of records included in this review was 126. One hundred and two of these studies were RCTs, while 24 were reviews and meta-analyses. The role of omega-3 fatty acids was studied in schizophrenia, major depression, bipolar disorder, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, eating disorders, substance use disorder and borderline personality disorder. The main evidence of the efficacy of omega-3 fatty acids has been obtained in treating depressive symptoms in patients with major depression and, to a lesser degree, bipolar depression. Some efficacy was also found in early phases of schizophrenia in addition to antipsychotic treatment, but not in the chronic phases of psychosis. Small beneficial effects of omega-3 fatty acids were observed in ADHD and positive results were reported in a few trials on core symptoms of borderline personality disorder. For other psychiatric disorders results are inconsistent.

Early Interventions for the Prevention of Posttraumatic Stress Symptoms in Survivors of Critical Illness: A Qualitative Systematic Review

OBJECTIVES

Posttraumatic stress disorder among survivors of critical illness is of public health importance, as it is common and reduces patient quality of life. The objective of this systematic review was to collate the world's literature on interventions aimed at preventing posttraumatic stress disorder among survivors of critical illness.

DATA SOURCES

We performed a search of CENTRAL, MEDLINE, EMBASE, CINAHL, and clinical trials registry platforms, with no restriction to language using a comprehensive strategy.

STUDY SELECTION

Study inclusion criteria were as follows: 1) adult human subjects, 2) patients treated in an ICU setting, 3) intervention arm aimed at reducing posttraumatic stress disorder symptoms, 4) use of a control arm, and 5) an outcome measure assessing development of acute stress or posttraumatic stress disorder symptoms.

DATA EXTRACTION

We performed a qualitative analysis to collate and summarize effects of identified interventions according to the recommended methodology from the Cochrane Handbook.

DATA SYNTHESIS

Seventeen studies met all inclusion and no exclusion criteria. There was heterogeneity in interventions and outcome measures used. All studies had some concern for risk of bias as per the Cochrane tool for assessing risk of bias. In eight of 12 studies (67%) testing early interventions (i.e., initiated in the ICU course) and one of five studies (20%) testing delayed interventions following ICU discharge, posttraumatic stress disorder symptoms were decreased among the intervention group compared with controls.

CONCLUSIONS

Despite a paucity of high-quality clinical investigations, the preponderance of evidence to date suggests that 1) posttraumatic stress disorder among survivors of critical illness may be preventable and 2) early interventions may be the most effective.

Trim the fat: the role of omega-3 fatty acids in psychopharmacology

The American Psychiatric Association (APA) currently recommends the use of omega-3 fatty acid supplementation for depressive disorders, impulse-control disorders, and psychotic disorders in treatment guidelines. This review examines the evidence for efficacy of omega-3 fatty acids in depressive disorders, bipolar disorder, anxiety disorders, post-traumatic stress disorder (PTSD), and psychosis. Meta-analysis of randomized-controlled trials of omega-3 fatty acids for depression are inconclusive, with strong evidence of publication bias, sizable heterogeneity between included studies, and substantial methodological shortcomings in included trials. The large amount of heterogeneity in findings of RCTs of omega-3 fatty acids for unipolar depression is likely attributable to highly heterogeneous sample populations that are given different omega-3 supplements [which differ widely in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) content, ratio, and dosage] as either adjunctive or monotherapy of other existing treatments, and then measure several different outcomes of depression symptomatology with likely incomplete blinding. Evidence of efficacy of omega-3 supplementation in treating psychosis, PTSD, anxiety, and bipolar mania is minimal. The current guidelines recommending the use of omega-3 fatty acids in adulthood psychiatric conditions should be revisited, especially given several recent negative studies examining the effects of omega-3 fatty acids for cardiovascular disease. Recommending likely ineffective treatment to patients, no matter how benign the side-effect profile, has opportunity cost (e.g. other more effective medications or therapies not being utilized) and likely affects patient compliance with other evidence-based treatments.

Theranostic pharmacology in PTSD: Neurobiology and timing

Recent reviews and treatment guidelines regard trauma-focused cognitive-behavior therapies as the treatments of choice for chronic post-traumatic stress disorder (PTSD). However, many patients do not engage in this treatment when it is available, drop out before completion, or do not respond. Medications remain widely used, alone and in conjunction with psychotherapy, although the limitations of traditional monoamine-based pharmacotherapy are increasingly recognized. This article will review recent developments in psychopharmacology for PTSD, with a focus on current clinical data that apply putative neurobiologic mechanisms to medication use-i.e., a theranostic approach. A theranostic approach however, also requires consideration of timing, pre, peri or post trauma in conjunction with underlying dynamic processes affecting synaptic plasticity, the HPA axis, hippocampal activation, PFC-amygdala circuitry and fear memory.

A comparison of physical comorbidities in patients with posttraumatic stress disorder developed after a terrorist attack or other traumatic event

No study investigated whether the presence of specific medical comorbidities is associated with the type of traumatic event, in particular with terrorist attack (TA). In a group of subjects with posttraumatic stress disorder (PTSD), the current study investigated the association between the types of traumatic event (TA vs. other traumatic event [OTE]) and medical comorbidities, controlling for sex and PTSD duration. The Mini International Neuropsychiatric Interview, the Clinician-Administered PTSD Scale, and the Davidson Trauma Scale were administered to 84 subjects diagnosed with PTSD. Thirty-nine were victims of TA and 45 victims of OTE. TA was associated with higher prevalence of neoplasms (β = 2.60, p = 0.02). Females were more protected than males from circulatory system comorbidities (β = 1.47, p = 0.04), while PTSD duration was associated with higher prevalence of such comorbidities (β = 0.005, p = 0.01). Females showed a higher prevalence of neoplasms than males (β = 2.50, p = 0.02). Female sex was protective against metabolic syndrome (β = -1.79, p = 0.02). Patients with PTSD due to TA and female patients should be considered for their higher prevalence of neoplasms, while male patients and those with higher symptom duration should be monitored for circulatory disease and metabolic syndrome. Symptom duration might be associated with circulatory and metabolic disease. Implications for tailored and timely psychopharmacological and psychotherapeutic intervention for PTSD are discussed focusing on these specific medical comorbidities.

The emerging role of omega-3 fatty acids as a therapeutic option in neuropsychiatric disorders

The prevalence of neurologic and psychiatric diseases has been increasing for decades and, given the moderate therapeutic efficacy and safety profile of existing pharmacological treatments, there is an urgent need for new therapeutic approaches. Nutrition has recently been recognized as an important factor for the prevention and treatment of neuropsychiatric disorders. The omega-3 polyunsaturated fatty acids (n-3 PUFAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) play critical roles in neuronal cell function and neurotransmission as well as inflammatory and immune reactions that are involved in neuropsychiatric disease states. A large number of experimental and epidemiological studies provide a strong basis for interventional clinical trials that assessed the clinical efficacy of n-3 PUFAs in various neurological and psychiatric disorders. Most of these trials found beneficial effects of dietary supplementation with EPA and DHA, and no serious safety concerns have emerged. This review gives an introduction to recent findings on the clinical efficacy of n-3 PUFAs in various neuropsychiatric disorders and the underlying biochemical mechanisms. In addition, the reader will be enabled to identify common methodological weaknesses of clinical studies on n-3 PUFAs, and suggestions for the design of future studies are given.

Anxiolytic properties of compounds that counteract oxidative stress, neuroinflammation, and glutamatergic dysfunction: a review

Objective:

Anxiety disorders are highly prevalent and the efficacy of the available anxiolytic drugs is less than desired. Adverse effects also compromise patient quality of life and adherence to treatment. Accumulating evidence shows that the pathophysiology of anxiety and related disorders is multifactorial, involving oxidative stress, neuroinflammation, and glutamatergic dysfunction. The aim of this review was to evaluate data from animal studies and clinical trials showing the anxiolytic effects of agents whose mechanisms of action target these multiple domains.

Methods:

The PubMed database was searched for multitarget agents that had been evaluated in animal models of anxiety, as well as randomized double-blind placebo-controlled clinical trials of anxiety and/or anxiety related disorders.

Results:

The main multitarget agents that have shown consistent anxiolytic effects in various animal models of anxiety, as well in clinical trials, are agomelatine, N-acetylcysteine (NAC), and omega-3 fatty acids. Data from clinical trials are preliminary at best, but reveal good safety profiles and tolerance to adverse effects.

Conclusion:

Agomelatine, NAC and omega-3 fatty acids show beneficial effects in clinical conditions where mainstream treatments are ineffective. These three multitarget agents are considered promising candidates for innovative, effective, and better-tolerated anxiolytics.

Inter-Method Reliability of Pulse Volume Related Measures Derived Using Finger-Photoplethysmography

Abstract. Pulse volume (PV) and its related measures, such as modified normalized pulse volume (mNPV), direct-current component (DC), and pulse rate (PR), derived from the finger-photoplethysmogram (FPPG), are useful psychophysiological measures. Although considerable uncertainties exist in finger-photoplethysmography, little is known about the extent of the adverse effects on the measures. In this study, we therefore examined the inter-method reliability of each index across sensor positions and light intensities, which are major disturbance factors of FPPG. From the tips of the index fingers of 12 participants in a resting state, three simultaneous FPPGs having overlapping optical paths were recorded, with their light intensity being changed in three steps. The analysis revealed that the minimum values of three coefficients of Cronbach’s α for ln PV, ln mNPV, ln DC, and PR across positions were .948, .850, .922, and 1.000, respectively, and that those across intensities were .774, .985, .485, and .998, respectively. These findings suggest that ln mNPV and PR can be used for psychophysiological studies irrespective of minor differences in sensor attachment positions and light source intensity, whereas and ln DC can also be used for such studies but under the condition of light intensity being fixed.

Are Long-Chain Polyunsaturated Fatty Acids the Link between the Immune System and the Microbiome towards Modulating Cancer?

Three recent studies revealed synergy between immune-checkpoint inhibitors and the microbiome as a new approach in the treatment of cancer. Incidentally, there has been significant progress in understanding the role of polyunsaturated fatty acids (PUFAs) in modulating cancer and the immune system, as well as in regulating the microbiome. Inflammation seems to be the common denominator among these seemingly unrelated biological entities-immune system, the microbiome, and long-chain polyunsaturated fatty acids (LC-PUFAs). This commentary presents a hypothesis proposing the existence of an optimal level of LC-PUFAs that nurtures the suitable gut microbiota preventing dysbiosis. This synergy between optimal LC-PUFAs and gut microbiota helps the immune system overcome the immunosuppressive tumour microenvironment including enhancing the efficacy of immune checkpoint inhibitors. A model on how LC-PUFAs (such as omega(n)-3 and n-6 fatty acids) forms a synergistic triad with the immune system and the microbiome in regulating inflammation to maintain homeostasis is presented. The principles underlying the hypothesis provide a basis in managing and even preventing cancer and other chronic diseases associated with inflammation.

Association of Use of Omega-3 Polyunsaturated Fatty Acids With Changes in Severity of Anxiety Symptoms: A Systematic Review and Meta-analysis

IMPORTANCE

No systematic review or meta-analysis has assessed the efficacy of omega-3 polyunsaturated fatty acids (PUFAs) for anxiety.

OBJECTIVE

To evaluate the association of anxiety symptoms with omega-3 PUFA treatment compared with controls in varied populations.

DATA SOURCES

PubMed, Embase, ProQuest, ScienceDirect, Cochrane Library, ClinicalKey, Web of Science, and ClinicalTrials.gov databases were searched up to March 4, 2018.

STUDY SELECTION

A search was performed of clinical trials assessing the anxiolytic effect of omega-3 PUFAs in humans, in either placebo-controlled or non-placebo-controlled designs. Of 104 selected articles, 19 entered the final data extraction stage.

DATA EXTRACTION AND MEASURES

Two authors independently extracted the data according to a predetermined list of interests. A random-effects model meta-analysis was performed and this study was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

MAIN OUTCOMES AND MEASURES

Changes in the severity of anxiety symptoms after omega-3 PUFA treatment.

RESULTS

In total, 1203 participants with omega-3 PUFA treatment (mean age, 43.7 years; mean female proportion, 55.0%; mean omega-3 PUFA dosage, 1605.7 mg/d) and 1037 participants without omega-3 PUFA treatment (mean age, 40.6 years; mean female proportion, 55.0%) showed an association between clinical anxiety symptoms among participants with omega-3 PUFA treatment compared with control arms (Hedges g, 0.374; 95% CI, 0.081-0.666; P = .01). Subgroup analysis showed that the association of treatment with reduced anxiety symptoms was significantly greater in subgroups with specific clinical diagnoses than in subgroups without clinical conditions. The anxiolytic effect of omega-3 PUFAs was significantly better than that of controls only in subgroups with a higher dosage (at least 2000 mg/d) and not in subgroups with a lower dosage (<2000 mg/d).

CONCLUSIONS AND RELEVANCE

This review indicates that omega-3 PUFAs might help to reduce the symptoms of clinical anxiety. Further well-designed studies are needed in populations in whom anxiety is the main symptom.

Mechanisms underlying the effects of n-3 polyunsaturated fatty acids on fear memory processing and their hypothetical effects on fear of cancer recurrence in cancer survivors

The relationship of n-3 polyunsaturated fatty acids (PUFAs) and gut microbiota with brain function has been extensively reported. Here, we review how n-3 polyunsaturated fatty acids affect fear memory processing. n-3 PUFAs may improve dysfunctional fear memory processing via immunomodulation/anti-inflammation, increased BDNF, upregulated adult neurogenesis, modulated signal transduction, and microbiota-gut-brain axis normalization. We emphasize how n-3 PUFAs affect this axis and also focus on the hypothetical effects of PUFAs in fear of cancer recurrence (FCR), the primary psychological unmet need of cancer survivors. Its pathophysiology may be similar to that of post-traumatic stress disorder (PTSD), which involves dysfunctional fear memory processing. Due to fewer adverse effects than psychotropic drugs, nutritional interventions involving n-3 PUFAs should be acceptable for physically vulnerable cancer survivors. We are currently studying the relationship of FCR with n-3 PUFAs and gut microbiota in cancer survivors to provide them with a nutritional intervention that protects against FCR.

Effect of omega-3 long-chain polyunsaturated fatty acid supplementation on heart rate: a meta-analysis of randomized controlled trials

Background

Elevated resting heart rate (HR) has emerged as a new risk factor for all-cause and cardiovascular mortality. The effect of marine-derived omega-3 long-chain polyunsaturated fatty acid (n−3 LCPUFAs) supplementation on HR was investigated as an outcome in many clinical trials. The present study was to provide an updated meta-analysis on the HR-slowing effect of n−3 LCPUFAs, and to differentiate the chronotropic effect between eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

Methods

PubMed and Cochrane databases were searched for relevant articles examining the effects of n−3 PUFAs on HR through May 2017. A random-effects model was used to generate the pooled effect sizes and 95% confidence intervals (CIs). The pooled effect sizes were presented as weighted mean differences (WMDs).

Results

A total of 51 randomized controlled trials (RCTs) with approximately 3000 participants were included in this meta-analysis. Compared to placebo, n−3 PUFA supplementation mildly but significantly reduced HR (−2.23 bpm; 95% CI: −3.07, −1.40 bpm). Moderate evidence of heterogeneity was observed among included trials (I² = 49.1%, P heterogeneity < 0.001). When DHA and EPA were separately administered, modest HR reduction was observed in trials that supplemented with DHA (−2.47 bpm; 95% CI: −3.47, −1.46 bpm), but not in trials with EPA.

Conclusions

The present meta-analysis provides strong clinical evidence demonstrating the effect of heart rate reduction by n−3 LCPUFA supplementation. When DHA or EPA administered alone, heart rate was slowed by DHA rather than by EPA.

Limited effect of omega-3 fatty acids on the quality of life in survivors of traumatic injury: A randomized, placebo-controlled trial

Empirical evidence is divided on whether n-3 polyunsaturated fatty acid levels are associated with quality of life (QOL). This study investigated the effects of docosahexaenoic acid (DHA) supplementation on QOL in survivors of traumatic injury. In this secondary analysis of a double-blind, randomized controlled trial, we recruited 110 trauma patients (82% men; mean age, 39.6 years) in an intensive care unit. Fifty-three received DHA-rich supplements and 57 received placebo for 12 weeks. We used the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) to assess QOL at the end of intervention. DHA did not significantly affect any QOL domain on the SF-36 after 12 weeks. In the DHA group, changes in the erythrocyte levels of eicosapentaenoic acid (EPA) + DHA and EPA were positively correlated with the SF-36 mental component. DHA did not influence QOL of trauma patients, but increased EPA levels during the trial were associated with better QOL in patients receiving omega-3.

Novel pharmacological treatment strategies for posttraumatic stress disorder

INTRODUCTION

A wide range of medications have been studied for posttraumatic stress disorder (PTSD) and a number are registered for this indication. Nevertheless, current pharmacotherapies are only partially effective in some patients, and are minimally effective in others. Thus novel treatment avenues need to be explored. Areas covered: In considering novel pharmacological agents for the treatment of PTSD, this paper takes a translational approach. We outline how advances in our understanding of the underlying neurobiology of PTSD may inform the identification of potential new treatment targets, including glutamatergic, noradrenergic and opioid pathways. Expert commentary: Continued investigation of the neural substrates and signalling pathways involved in responses to trauma may inform the development of novel treatment targets for future drug development for PTSD. However, the translation of preclinical findings to clinical practice is likely to be complex and gradual.

Advanced Volume-Compensation Method for Indirect Finger Arterial Pressure Determination: Comparison with Brachial Sphygmomanometry

OBJECTIVE

The so-called volume-compensation method (VCM) allows noninvasive instantaneous arterial blood pressure (BP) measurement in human fingers. The VCM is mostly carried out with photoplethysmography (PPG) to detect arterial volume pulsations. However, measurement errors may occur due to movement of the PPG sensors relative to skin and underlying vasculature. We report here the effectiveness of a new technique, "advanced VCM" (AVCM), developed by us to resolve this significant problem.

METHODS

The AVCM described uses a control system with procedures for adjusting system parameters derived from the pulsatile PPG signal and the finger cuff pressure. In open loop pre-operation, mean BP is estimated from a finger using the volume-oscillometric method. The control system reference is then adjusted to yield approximately equal values in mean BP and this gives optimum performance for instantaneous BP measurement. Systolic and diastolic BP values (SBP, DBP) from the instantaneous BP by the VCM and the AVCM were compared with the conventional brachial SBP/DBP measured simultaneously during 5-min baseline. SBP/DBP from the AVCM were also compared with brachial SBP/DBP during 36-min bicycle ergometer exercise.

RESULTS

Measurement errors that occurred when the BP measurement was run using the previous VCM essentially disappeared in the AVCM. Bland-Altman analysis revealed negligible fixed and proportional bias between finger SBP/DBP and brachial SBP/DBP.

CONCLUSION

These findings suggest that the AVCM could be an effective technique to resolve the problem of measurement errors occurring with standard VCM.

SIGNIFICANCE

The newly proposed AVCM is potentially useful for all research and clinical situations where noninvasive continuous BP measurement is needed.